Seniors May Find Drug Benefit Lacking

LAURA MECKLER

Published 8:00 pm, Monday, June 16, 2003

Associated Press Writer

Seniors expecting a generous Medicare prescription drug benefit from Congress are likely to be disappointed. Most will find the government paying only a fraction of their pharmacy bills and far less than most working Americans have come to expect from private insurance.

Both House and Senate bills would require senior citizens to spend a significant amount of their own money in order to receive significant government benefits. And both plans include a complicated feature not found in the private market: Coverage would disappear after drug costs reached a certain level and then would resume only if costs reached a much higher plateau.

"I think many will be disappointed because the benefit is so skimpy compared to that most Americans are familiar with," said Robert Reischauer, former director of the Congressional Budget Office.

Democrats voiced similar concerns as the legislation moved toward passage on both sides of the Capitol. Two House committees began work Tuesday, and in the Senate, members prepared to consider a series of amendments during floor debate. House and Senate passage of the separate bills by the July 4 recess seemed certain.

Many Senate Democrats were prepared to support the final bill, but they warned against overselling it.

"We may create false expectations, high expectations that just will not be realized once the full impact of the bill is felt in the countryside," said Minority Leader Tom Daschle of South Dakota.

Outside experts in health policy and public opinion agreed.

Reischauer, now president of the Urban Institute, a policy research think tank, said most current and future retirees will expect a benefit that is closer to what employers offer their workers.

Medicare beneficiaries who have no drug coverage at all today, he added, "should be satisfied but far from ecstatic."

That's a long way from much of the rhetoric coming from Capitol Hill, where many lawmakers are trumpeting the new drug benefits as nothing short of historic.

In private health insurance plans, people usually pay a small fee for each prescription _ $5 or $10. Sometimes they have a deductible that requires them to spend a certain amount of money before insurance starts paying for anything.

The Medicare drug plans are considerably more complicated.

First off, under both bills participants must pay a $35 monthly premium to participate.

Under the Senate bill, seniors would have a $275 deductible. Insurance would then cover half their drug costs, from $276 to $4,500. There would be no coverage at all from $4,500 to $5,800. At that point, seniors will have spent $3,700 out of their own pockets. After that, insurance would pay 90 percent of the cost.

The House bill uses a similar formula. The deductible would be $250. Insurance would cover 80 percent of the costs from $251 to $2,000. There would be no coverage from $2,000 to $4,900. At that point, seniors will have spent $3,500 out of their pockets. After that, insurance would cover 100 percent.

To Reischauer, it's an arrangement "not found in nature." Still, he said, most will probably opt into the program because if they don't and they need it later, it will be much more expensive to sign up.

The benefits are much better for low-income seniors, particularly the poorest, who won't have to pay premiums and will get much larger government contributions toward their drug bills. And most seniors don't spend enough on drugs to ever fall into the coverage gap.

Sen. Charles Grassley, chairman of the Finance Committee, said seniors will be well equipped to make that decision when the time comes.

"They will make a choice: Is it a good buy for them or is it not a good buy?" said the Iowa Republican.

The coverage gaps were included to keep the cost of the program down. Congress has agreed to spend $400 billion over 10 years on Medicare, and it would cost much more to offer a more comprehensive benefit.

Most people are not following the details of the congressional debate, but polling and focus groups suggest they expect a drug benefit that resembles what private employers offer, said Robert Blendon, longtime health pollster at Harvard School of Public Health.

"They'll discover it's a lot less," he said.

The Medicare plans being debated will cover just 22 percent of senior citizens' total drug costs. The rest will be paid by the seniors themselves; by Medicaid, the program for the poor, and by employee retirement plans.

Blendon predicted that within a few years there will be pressure on Congress to increase the benefit, though the issue will no longer be a top-line political priority.

For now, some supporters say lawmakers would do well to keep expectations in line with reality.

"It's important to minimize hype," said Sen. Max Baucus, D-Mont., one of the plan's chief sponsors. "There's almost always an adverse reaction to hype."